Here's the study guide for Nursing 1 with answers we've all provided, put together by Cheryl. Good luck everyone!
1. Discuss the risk factors for complications of the patient undergoing surgery.Age: immature and declining physical status. Mortality rate hit her in very young and very old. Infants at risk to maintain body temperature.
Nutrition: tissue repair and resistance to infection
Obesity: increases the risk of reducing ventilation and cardiac function
Obstructive Sleep apnea: associated w/oxygen desaturation.
Immunocompromise: increased risk for infection
F & E imbalance: decreased tissue healing and increased risk for infection.
Pregnancy: risk for operative complications are increased
2. Discuss the signs and symptoms of the patient experiencing dyspnea.SOB (exercise/excitement)
Used of accessory muscles
Increased rate and depth of respirations
Nasal flaring
3. Discuss the nurse’s responsibility to safe medication administration.Critical thinking skills
Take time to read MAR
Review client hx
Review physical exam
Look up meds if not known
Why client taking meds?
Responsibility/accountability
Do not assume =0 A
Familiarize w/therapeutic effect
Usual dosage
Anticipated changes in lab data, side effects
SIX RIGHTS: med, dose, client, route, time, documentation
4. Discuss the responsibility of the nurse when a medication error has occurred.Prepare occurrence or incident report w/in 24 hrs (location, time factual description, signature)
Notify physician
Notify patient
Notify person in charge
5. Discuss the nursing actions that will maintain dignity and respect to the patients.Always provide for privacy when talking with a client. Whether that means closing a door, curtain, or asking if the client wants to have family members present when discussing healthcare matters, it is important to provide the person with privacy and to respect the need for privacy.
Respect, it is always very important to maintain respect for a person’s culture, customs and beliefs, don’t cast judgment regardless of if the nurse believes that they are important or not.
When you are talking with a client it is important to talk with them and not at them keeping the lines of communication open, use of medical jargon should be avoided because most people won’t be able to understand it. You should never talk down to the client or seem condescending. Ask the client if they understand and if they have any questions or concerns and never rush the client. Active listening means being attentive to what the client is saying both verbally and nonverbally. The appropriate use of nonverbal communication, if the client is crying, venting, or not talking, it is ok to just be there for the client without having verbal communication.
6. Discuss the nursing interventions to promote communication with a patient with aphasia.It is very important for the nurse to first establish a way that the aphasic person can communicate through nonverbal communication. First the nurse needs to establish that the aphasic person is cognitively present. If the person is AOX himself and possible place, or understands why they are in the hospital, the nurse should look for a way to communicate. The nurse should establish if the person can move their head and if the person can, ask yes or no questions and ask the client to nod his head for yes and shake for no. The nurse has to communicate this to the client or the client won’t know how to respond when the nurse asks a question. If possible find out if the client is able to write. If the client is able to write, the nurse can ask the client to write the responses to the questions that the nurse is asking. The nurse could use pictures when trying to communicate with the aphasic person, asking them to point if possible to the picture that describes how the person feels, or conveys the message that the client is trying to make.
7. Discuss the purpose of the implementation phase of the nursing process.When the nurse establishes an intervention or decides on the plan of care that is based upon the nursing diagnosis of the client. The interventions have to be implemented in order to achieve the goal or outcome that the nurse has decided on for the client. During implementation the nurse must reassess the client to make sure that the interventions that have been implemented are achieving the desired outcomes, or if the implementation of the intervention is having a negative impact on the client. After reassessing the care plan, the nurse needs to review the care plan, comparing the assessment data to validate the nursing diagnoses, and to determine if the interventions are still necessary for that client. Organizing the resources that the client needs to have for care to be delivered is another important step in the implementation process. Anticipating and preventing complications from the interventions is something else that the nurse needs to be alert for while implementing the interventions.
8. Discuss the purpose of open-ended questions when obtaining subjective data.We all know that Mrs. Semillo loves to say it depends, but she also likes to say KEEP IT SIMPLE. I think that one of the most important things to remember when being in the clinical environment is to keep the questions simple. Of course, IT DEPENDS on the situation. Some questions have to be more detailed than others. The point is, when asking clients questions we don’t want to receive yes or no answers. Ex. You have a client that tells you that she is allergic to peanuts. Your response wouldn’t be: What makes you think you’re allergic to peanuts. To me that has a negative undertone and if someone asked me that I may get an attitude. Because I don’t THINK that I am allergic to peanuts, I KNOW that I am allergic to peanuts, I understand why that wouldn’t be the BEST response when asking a client an open-ended question. A better question that would elicit more information would be Tell me what happens when you eat peanuts. For one the client is going to tell you exactly what happens when they eat peanuts like, Well my tongue swells, my eyes bulge out of my head and I throw up like the little girl from Poltergeist. ON THURSDAY DURING THE LAST LECTURE MRS. SEMILLO SAID SOMETHING VERY PROFOUND “Use your common sense when going through the test, the scenario’s and looking for answers.” I think if we do this along with the other things that we have learned during this course you will know an open-ended question from a closed question.
9. Discuss the nursing interventions to prevent vascular complications for an immobile patient.Interventions include education, prevention, and early detection. Apply Ted stockings and SCD’s which need to be removed every 8 hours to access for redness, warmth and tenderness. Exercise (ankle pumps, foot circles and knee flexion), Range of motion (ROM). Mobilize the patient as soon as physical condition allows, even if this only involves dangling at the bedside or moving to a chair. Regularly providing fluids, and position changes. Other interventions such as medications (heparin), intermittent pneumatic compression (IPC) and SCDs require a health care providers order.
10. Differentiate between evaluation and assessment.EVALUATION: Evaluation is an ongoing process whenever you have contact with a client. Once you deliver an intervention, gather subjective and objective data from the client family and health care team members. You also review knowledge regarding the client’s current condition treatment resources available for recovery and the expected outcomes.
ASSESSMENT: Assessment is the deliberate and systematic collection of data to determine a client’s current and past health status and functional starts and to determine the client’s present and past coping patterns. 2 steps. 1. Collection and verification of data from a primary (client) and secondary (family past records) source. 2. The analysis of all data as a basis for developing nursing diagnoses, identifying collaborative problems and developing a plan of individualized care.
11. Explain autonomy. Provide examples.Autonomy is the ability to be self directed and independent in accomplishing goals and advocating for others. There are independent nursing interventions you will initiate without medical orders. Autonomy is also the commitment to include clients in decisions about all aspects of care.
Examples:
1. The consent that clients read and sign before surgery illustrates this respect for autonomy. The signed consent ensures that the health care team obtained permission from the client before proceeding with the surgery.
2. A nurse has the autonomy to develop and implement a discharge teaching plan based on specific client needs for any client who has been hospitalized. The nurse provides nursing care that complements the prescribed medical therapy.
3. Implementing coughing and deep breathing exercises for a new postoperative client.
Consult with other health professionals to pursue the best treatment plan for your patient.
12. Discuss the nursing responsibilities for the patient while in the PACU.Nursing care in the PACU focuses on monitoring and maintaining airway, respiratory, circulatory and neurological status and on managing pain. On immediate admission “handoff” the nurse takes vital signs and completes a full physical assessment. Patients often receive some form of oxygen in the immediate recovery period.
13. Discuss strategies to ensure safe administration of medication.*Follow the 10 rights of medication administration. 1. Right client (2 forms of identification) 2. Right medication (3 checks) 3. Right dose 4. Right route
5. Right time 6. Right client education (information about the medication)
7. Right documentation 8. Right to refuse 9. Right assessment
10. Right evaluation.
*Be sure to read labels at least three times (comparing medication administration record (MAR) with label) before administering the medication.
*Use at least two client identifiers whenever administering a medication.
*Do not allow any other activity to interrupt administration of medication to a client.
*Double-check all calculations, and verify with another nurse.
*Do not interpret illegible handwriting; clarify with prescriber.
*Question unusually large or small doses.
*Document all medications as soon as they are given.
*When you have made an error, reflect on what went wrong and ask how you could have prevented the error.
*Evaluate the context or situation in which a medication error occurred. This helps to determine if nurses have the necessary resources for safe medication administration.
*When repeated medication errors occur within a work area, identify and analyze the factors that may have caused the errors and take corrective actions.
*Attend in-service programs that focus on the medications commonly administered.
14. Discuss the assessment needed for the patient with fluid imbalance.*Age (very young & very old are more vulnerable)
*Past Medical History: Acute recent illness, surgery extensiveness, burn severity, respiratory disorders (pneumonia), head injury, chronic illness (cancer, cardiovascular disease, renal disorders, GI disturbances), environmental factors (extreme temperatures), diet (acidosis), lifestyle (smoking, ETOH), medication (OTC drugs that cause electrolyte & acid-base disturbances)
*Physical assessment: I&O, daily weight, lab studies (BUN, ABG, Hct, serum electrolyte level), edema
*Assessment questions: Nature of problem, signs & symptoms, severity, predisposing factors, effect on client)
15. List the criteria for writing a correct outcome or goal.Criteria’s are: Client-Centered- outcomes and goals reflect the client behavior and responsesexpected as a result of nursing intervention. Singular- be precise in evaluating a client responseto a nursing action. Each goal and outcome addresses only one behavior or response. Observable- You need to be able to observe if change takes place in a client’s status.
Observable changes occur in physiological findings and the client’s knowledge, perceptions,and behavior. Measurable- You will learn to write goals and expected outcomes that set standards against which to measure the client’s response to nursing care. Terms describing quality, quantity, frequency, length, or weight allow you to evaluate outcomes precisely.
Time-Limited- The time frame for each goal and expected outcome indicates when you expectthe response to occur. Time frames assist you and the client in determining if the client is making progress at a reasonable rate. Manual Factors- Mutually set goals and expected outcomes ensure that the client and nurse agree on the direction and time limits of care. Mutual goal setting increases the client’s motivation and cooperation. Realistic- Set goals and expected outcomes that a client is able to reach. Realistic goals provide clients a sense of hopethat increases motivation and cooperation.
16. Discuss the criteria needed for writing an accurate nursing diagnosis.The North American Nursing Diagnosis Association (NANDA) defined nursing diagnosis as "a clinical judgement about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable." The purpose of the NANDA diagnosis it provides nurses with a common frame of reference and standardizes language that improves communication among nurses, helps organize research, and is useful in educating new practitioners. Nursing diagnoses provide a classification system to describe the scientific foundation of nursing practices—a major criterion necessary for nursing to be recognized as a separate profession, differentiated from medicine and other health care professions. It is important to distinguish nursing diagnoses from medical diagnoses. The two are similar because they are both designed to plan care for a patient. However, nursing diagnoses focus on human response to stimuli, while medical diagnoses focus on the disease process. The term "nursing diagnosis" refers to items on the NANDA list of approved diagnoses. The term "nursing diagnostic statement" refers to the approved or accepted way in which a nursing diagnosis is written in practice. Three structural components of a nursing diagnostic statement: the problem, the etiology (cause), and the signs and symptoms. In order to make an appropriate nursing diagnosis, the practitioner must conduct an in-depth interview, physical assessment, and critical observation of the individual, family, or community for which the diagnosis is being made. A complete nursing assessment includes: the patient's current health status, signs and symptoms, strengths, and problem areas. The patient (who can be an individual, a family, or a group) should be the primary source of assessment data. After compiling data through assessment, the data are grouped or organized into categories that will assist the nurse in identifying appropriate diagnoses. A variety of organizing frameworks exist to assist the nurse in organizing the data, including NANDA's human response patterns.
17. Discuss strategies that promote effective communication.Follow legal, ethical, and clinical standard, Understanding the communication process, reflection about one's communication experience, and the following Critical thinking attitudes promotes effective communication
Curiosity- motivates the nurse to communicate and to know more about the pt. It increases client's willingness to communicate.
Perseverance and creativity- motivates the nurse to communicate and identify effective innovative solutions.
Self confidence- helps to establish interpersonal helping- trust relationships.
Independent attitude- encourages the nurse to communicate with colleagues and share ideas about nursing intervention.
Fairness- ability to listen to both sides in any discussion.
Integrity- allows the nurse to recognize when their opinion conflicts with those of the clients and to decide how to communicate to reach mutual decision,
Humility- helps to recognize and communicate the need for more information before decision making.
Therapeutic communication like active listening, empathy, sharing hope, humor, feeling, using silence, providing information, clarifying, focusing, paraphrasing, asking relevant questions, summarizing, self disclosure, and confrontation encourages the expression of feelings, ideas, and convey acceptance and respect.
18. Discuss the role of the health care team when developing an initial plan of care.
- making admission assessment
-initial selection of nursing diagnosis and collaborative problems
-prioritize the problem
-identify desired out come
-identify intervention
-prioritize intervention
19. Compare and contrast legal decision making and ethical and moral principles.Understanding the law protects health care professional from liability and the clients' right.
Legal responsibility
Informed consent- disclose the material of facts in terms the client understand to make an informed choice
Delegation- knowing what to delegate or not to delegate
Advance directive- living will and durable power of attorney
Report abuses, sexual harassment, and respect privacy (HIPAA).
Follow the proper policy in applying restraints, avoid false imprisonment.
Respect the client right, avoid assault and battery
Be competent, avoid negligence
Ethical and moral principles
It determines what is good or valuable for individuals, for groups, and for society. It promotes caring and compassionate behavior.
Autonomy- respects clients? ideas in health care decision making.
Beneficence- taking positive action to help others, doing to the best interest of the client.
Nonmalefiecence- avoid harm, evaluate the pro and cons before providing care
Justice- treats everybody equally and fairly.
Fidelity- keeps your promise.
-Be advocate to a client, be responsible and accountable for your action as a health care professional and protects clients privacy.
20. Discuss the nursing care of the patient with a urinary catheter.- use strict aseptic techniques in inserting catheter.
- After inserting an indwelling catheter, maintain a closed urinary drainage system to minimize the risk of infection.
-keep the catheter tubing free of sediments.
-place the drainage bag below the Pt's bladder.
-provide perineal care at least three times a day
-encourage fluid intake of 2000 to 2500 mL if permitted to keep the catheter tubing free of sediments.
-use sterile aseptic technique and maintain closed system when performing irrigation.
-use sterile technique in collecting specimen from a closed drainage system
-prevent pooling of urine in the tubing
-before exercise or ambulation drain all urine from the tubing to the bag
-avoid prolonged clamping or kinking of tubing
- Empty drainage bag at least every 8 hours.
- ensure every client has a separate receptacle for measuring urine to avoid cross contamination
- if the drainage tube becomes disconnected , do not touch the end of the catheter or tubing. Wipe the tip of the catheter or tubing with anti microbial agent before reconnecting.
-use clean technique when removing indwelling catheter.
21. Patient education needed for patient scheduled for surgery (p. 1379)-provide the pt with complete understanding of the surgery
-client should understand need for the procedure, steps involved, risks, expected results, alternative treatments
-prepare the client physically and psychologically for surgical intervention
-good pre-operative teaching has positive influence on pt recovery
-how implemented? Through telephone calls, mailings, preoperative teaching guidelines and checklists, use of videotapes or websites
-include family members in perioperative teaching: family member is usual coach for postoperative exercises after surgery. Also, anxious relatives heighten clients fear and anxiety
-provide clients with info on sensations usually felt after surgery: expected pain at surgical site, tightness of dressings, dryness of mouth, sensation of sore throat after endotracheal tube
-provide info to help client anticipate steps of a procedure
-explain and demonstrate postoperative exercises: diaphragmatic breathing, incentive spirometry, coughing, turning, leg exercises. These help prevent postoperative complications. Allow client time for independent practice and return to evaluate effectiveness before surgery.
-tell client and family approximate time of surgery and when they should arrive at the hospital. Surgeon informs client/family of anticipated length of surgery. Make client aware that delays do not necessarily indicate a problem
-orient client/family to location of postoperative unit. Orient family to where they can wait and where the surgeon will attempt to find them after surgery
-explain postoperative monitoring and therapies such as frequent vital signs monitoring, IV lines, monitoring lines, dressings, drainage tubes, ventilator support
-answer clients questions to clarify information about basic purpose of surgery. Augment Dr’s explanations. Inform Dr if client has little or no understanding about the surgery
-explain to client that it is normal to progress gradually in activity and eating after surgery. Some surgeries may let clients quickly resume normal physical activity and eating habits
-pain after surgery is expected. Inform client and family of available interventions for pain relief (analgesics, positioning, splinting, relaxation exercises). Client needs to know schedule for analgesic drugs, route, effects. Encourage use of analgesics at regular intervals to control pain so that client can participate in postoperative therapy. Explain length of time it takes for drug to start working.
-teach the client how to use PCA
-client and family needs time to express feelings about surgery. The more the anxiety, the more frequent the discussions need to be.
22. Nursing care of the patient who is confused (p. 1281; ND book p. 183)-pts who are confused or disoriented or who have changing levels of consciousness are unable to protect themselves from pressure ulcer development
-able to feel pressure but unable to understand how to relieve it or communicate their discomfort
-prevent overstimulation: maintain calm environment and lessen noise and distractions
-give simple directions and allow time for client to respond, communicate, and make decisions
-safety: call bell, needed items within reach
-provide for undisturbed rest periods
23. Complications of general anesthesia (p. 1392)- usual side effects of anesthetic agents, cardiovascular depression or irritability, respiratory depression, liver and kidney damage
-burns and other trauma can occur without the client being aware of the injury
-amnesia
-sudden fall in blood pressure
24. Nursing interventions to prevent thrombophlebitis in post-operative pt (p. 1247)-assess to identify risk factors for deep vein thrombosis (DVT)
-leg, foot, ankle exercises
-regularly providing fluids
-position changes
-give preoperative clients this info before surgery and get them out of bed as soon as possible
-medications, intermittent pneumatic compression (IPC) and sequential compression device (SCD)
-drugs: heparin and LMWH (low molecular weight heparin)
-assess for signs of bleeding when heparin or LMWH is given
-thromboembolic device (TED) hose: do not apply if pt has a local condition affecting the leg (such as skin lesions, gangrenous conditions, vein ligation) because this will compromise circulation
-teach clients to avoid the following: crossing the legs, sitting for prolonged periods of time, wearing clothing that constricts the legs or waist, putting pillows under the knees, massaging the legs
-ROM exercises to reduce the risk of contractures and aid in preventing thrombi
-specific exercises: ankle pumps, foot circles, knee flexion; these are called antiembolic exercises and are to be done hourly while awake
-when DVT is suspected, elevate the leg and report to physician. Instruct client, family, health care team not to massage the area to prevent dislodging the thrombus
29. Discuss the assessment needed for the patient with the diagnosis of Activity Intolerance.Remember: Know the rationales for each of the below. Rationales are too lengthy to type here, but we can discuss if we have group study at all.
Assess for:
Dyspnea or exertional discomfort, wheezing
Patient’s perception of causes of fatigue or activity intolerance
Patient’s level of mobility
Nutritional status
Potential for physical injury with activity
Ambulation aids: bracing, cane, walker, equipment modification for ADLs
BP changes
Need for oxygen with increased activity
Sleep pattern and amount of sleep
Rapid pulse (>100)
Palpitations in heart rhythm
Weakness, fatigue
Light headedness, dizziness, pallor, diaphoresis
Chest discomfort
Emotional status
30. Discuss the signs and symptoms of severe hypoxia/hypoxemia.Remember: Severe hypoxia is Late hypoxia - RAT (early) BED (late)
(see lecture notes)
Remember: Hypoxia is the lack of oxygen in the blood, affecting all tissues in the body
Bradycardia
Extreme Restlessness
Dyspnea (severe)
Anemia (insufficient number of RBC in tissues)
Decreased tissue perfusion (decreased SPO2 – normal is 80% - 100%)
Cyanosis
31. Discuss the nursing interventions needed to promote oxygenation of the post-operative patient.Remember: Oxygenation includes Respiratory (ventilation) and Circulatory (perfusion and circulation)
Remember: Oxygenation interventions prevent possible respiratory complications (on the respiration side), and decrease the risk of deep vein thrombosis (on the circulatory side).
Respiratory interventions Circulatory interventions
Deep breathing and coughing Leg exercises
Turning and positioning Turning and positioning
Early and aggressive ambulation Early ambulation
Use of incentive spirometry Use of antiembolic stockings
Use of compression devices
Adequate hydration
Anticoagulant propholaxis
32. Discuss the preparation needed to safely transfer the patient to the operating room.Remember: if patient ambulates, always check for lighting, clear walkway, and ortho hypotension.
Identify the right patient by reading the identification name band and by verifying the operative procedure.
Because some client receives preoperative drugs, the transporter and the nurse assist patient when transferring from bed to stretcher to prevent falls.
Have signed surgical consent form.
Attention to left and right operative sites for accuracy
Antiseptic on operative site (s).
Check vital signs (BP. Temp. pulse, and respiration rate). Notify physician of marked changes.
Asked patient if patient is allergic to iodine and latex, glasses, contact lenses.
Allergies to food, medications, chemicals.
Assist with putting on a hospital gown, hair cap, and if ordered, antiembolic hose.
Remove all jewelry.
Verify the NPO status to prevent aspiration.
Empty bladder.
Remove dentures, bridge work to prevent dislodge and airway obstruction during surgery.
Patient transferred feet first on the stretchers
33. Discuss the nursing interventions needed to promote ambulation.Remember: the main goal is to achieve early ambulation while safely maintaining the functions of the heart, fluid & electrolytes, nutrition & elimination, and patient’s comfort.
Establish guidelines and goals of activity with the patient and caregiver.
Encourage adequate rest periods, especially before meals, other ADLs, exercise sessions, and ambulation.
Refrain from performing nonessential procedures.
Anticipate the patient’s needs (e.g. keep telephone and tissues within reach).
Assist with ADLs as indicated; however, avoid doing for patients what they can do for themselves.
Provide bedside commode as indicated.
Encourage physical activity consistent with the patient’s energy resources.
Assist patients to plan activities for times when they have the most energy.
Encourage verbalization of feelings regarding limitations.
Progress activity gradually.
34. Discuss the assessment needed for the patient who has been on bed rest and has an order to begin ambulation. (1238-1239, 1275)Monitor all vitals, assess orthostatic blood pressures, check for edema, peripheral pulses, assess for deep vein thrombosis by examining lower legs. Assess range of motion and muscle strength.
While ambulating, constantly assess patient vitals including respiration rate and pulse. When walking, assess environment, assess for assistance needed, and establish potential rest points.
35. Discuss the purpose of bed rest. (1225)Many different interpretations, and used for clients with a wide variety of conditions, but four main objectives of bed rest: Reducing physical activity and the oxygen needs of the body, reducing pain including postoperative pain or after acute injury to the lower back, allowing ill or debilitated clients to rest, allowing exhausted clients the opportunity for uninterrupted rest.
36. Discuss the correct procedure for administering a subcutaneous medication.See skill 33-5 and Nursing Skills Online. Basically: Assess, prepare medication, have client relax, cleanse site, hold syringe as dart, spread skin with non-dominant hand, inject quickly at 45-90 degree angle, release skin, inject slowly, pull out, apply pressure but don't massage, discard needle and gloves.
37. Discuss the nursing care for the post-operative patient who had a nasogastric tube. (1398-1399)Specificallu for NG tube, assess for patency, and color and amount of gastric drainage. In general for post op gastrointestinal, inspect abdomen for distention, monitor for aspiration during oral intake, auscultate for bowel sounds, and ask about flatus.
38. Discuss the purpose of using an assistive device when moving patients. (1261)Reduce work related injuries for health care providers, some like the trapeze bar allow the client to help more. Some allow the nurse to move uncooperative patients as well as patients too large to move without an assistive device.
39. Discuss the correct procedure for suctioning a patient. (PP 934-940)There is just way too much stuff to type for these procedures. Please review Skill 40-1 on pages 934 through 940 of Potter and Perry for detailed directions.
* Also see ATI Fundamentals of Nursing book pages 639-642
40. Discuss the physiological effects of prolonged bed rest. (PP 1225-1228)* Also see ATI table on pages 481-483
* the individual of average weight and height and without a chronic illness on bed rest loses muscle strength from baseline levels at a rate of 3% a day.
* associated with cardiovascular, skeletal, and other organ changes
* tendency of cells and tissue to reduce in size and function
Systemic effects:
* disrupts normal metabolic functioning; decreases metabolic rate; alters metabolism of carbs, fats, and proteins; causes fluid, electrolyte, and calcium imbalances; decreased appetite and slowing of peristalsis.
* weight loss, decreased muscle mass, and weakness result from tissue catabolism
* calcium resorption from bones
* intestinal function may become depressed, dehydration may occur, absorption may cease, and F&E may be disturbed.
Respiratory changes:
* risk for developing pulmonary complications (atelectasis - collapse of alveoli, and hypostatic pneumonia.
Cardiovascular changes:
* orthostatic hypotension
* increased cardiac workload
* thrombus formation
Musculoskeletal changes:
* permanent or temporary impairment or permanent disability
* loss of endurance, strength, muscle mass and decreased stability and balance
* impaired calcium metabolism and impaired joint mobility
Muscle effects:
* loss of muscle mass, muscle weakness, disuse atrophy, loss of endurance
Skeletal effects:
* impaired calcium metabolism
* joint abnormalities & contractures/foot drop
Urinary elimination changes:
* urinary stasis
* renal calculi
Integumentary changes:
* pressure ulcers
41. Discuss dependent nursing interventions for the patient experiencing nausea. (All-in-One Care Planning Resource page 573)* give antiemetic as prescribed or OTC meds
* administer meds on empty stomach only when indicated
* offer food in small portions, 6 times per day
* give chewing gum or hard candies prn, if permitted
* suggest patient brush teeth and tongue q8hr and prn
* if odor of food induces nausea, remove food immediately
* reduce rate/min of enteral formula infusion
* if Pt. is receiving bolus infusion, change to intermittent or continuous
* inspect abdomen for distention and auscultate bowel sounds
* monitor for and record flatus and bowel movements
* if medically indicated, consider bowel suppository
* monitor electrolytes, especially potassium
* try dry foods (toast, crackers, etc) in morning and throughout day
* encourage ice chips
* encourage slow deep breathing
* wear loose-fitting clothes
42 Dosage and Calculations
Can you calculate pills/tablets/injections?
Can you calculate safe dosage ranges?
Can you safely administer medication (using the correct equipment)?* You are on you own here!! Review your Dimensional Diagnosis book
43. Can you utilize the nursing process given a specific case scenario?* Same here! Just think the case scenario through and apply all we have learned from our clinical experience and we will do great! Good luck to everyone.
